Anatomical Double-Bundle Medial Patellofemoral Ligament Reconstruction With Autologous Semitendinosus, a Single Patellar Tunnel Technique

Three different patellar fixation techniques yield similar clinical and radiological outcomes in recurrent patellar dislocation undergoing medial patellofemoral ligament reconstruction

PURPOSE

The purpose of this study was to evaluate and compare the clinical and radiological outcomes of three different patellar fixation techniques on medial patellofemoral ligament reconstruction (MPFLR) in the treatment of patellar dislocation (PD).

METHODS

Between 2015 and 2020, 130 patients with recurrent PD who underwent surgical reconstruction were eligible for this retrospective study: 48 patients were treated with the semi-tunnel bone bridge fixation technique (Group A), 42 patients were treated with the suture anchor fixation technique (Group B) and 40 patients were treated with the transpatellar tunnel fixation technique (Group C). Clinical outcomes included functional outcomes (Kujala, Lysholm and International Knee Documentation Committee scores), activity levels (Tegner activity score and return to sports), physical examinations, patellar re-dislocation rate and complications. Radiological outcomes included patellar congruence angle, patellar tilt angle, lateral patellar translation and lateral patellar angle.

RESULTS

All clinical and radiological outcomes improved significantly in all groups, without any significant difference among these three groups. At the final follow-up, no re-dislocation occurred, and all groups achieved a successful return to sports. However, the semi-tunnel bone bridge and suture anchor fixation techniques showed statistically higher Tegner activity scores (p = 0.004) and shorter time from surgery to return to sports (p = 0.007) than the transpatellar tunnel fixation technique.

CONCLUSION

The three MPFLR patellar fixation techniques achieved favourable and comparable clinical and radiological outcomes in the treatment of PD. Compared with the transpatellar tunnel fixation technique, the semi-tunnel bone bridge and suture anchor fixation techniques may be more effective with higher activity levels.

LEVEL OF EVIDENCE

Level III.

Surgical techniques for medial Patellofemoral ligament reconstruction: a systematic review and meta-analysis of level I and II studies

PURPOSE

To determine the most optimal surgical technique for medial patellofemoral ligament reconstruction (MPFLR).

METHODS

Three databases MEDLINE, PubMed, and EMBASE were searched from inception to December 13th, 2022, for level I or II studies comparing MPFLR techniques. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on patient-reported outcome measures were recorded. Quality assessment was carried out using the MINORS and Cochrane Risk of Bias assessment tools. Certainty of evidence was carried out with the GRADE assessment tool.

RESULTS

Ten studies comprising 723 patients (723 knees) were included in this review. The weighted mean difference in Kujala, Lysholm, and IKDC scores comparing single- and double-tunnel patellar drilling techniques was 2.66 (95% CI -1.05-6.37, p = 0.16, I2 = 0%) with moderate certainty, 0.78 (95% CI -9.02-10.58, p = 0.88, I2 = 87%) with low certainty, and 1.71 (95% CI -2.43-5.86, p = 0.42, I2 = 0%) with low certainty, respectively. Double-suture anchor patellar fixation demonstrated greater Kujala scores than transpatellar fixation (87.1 ± 2.8 vs 84.0 ± 3.8, p < 0.001) with moderate certainty. Y-shaped graft patellar fixation demonstrated superior Kujala scores to C-shaped graft patellar fixation (95.9 ± 4.7 vs 91.3 ± 9.7, p = 0.001) with moderate certainty. Augmentation of femoral fixation with polyester sutures demonstrated superior Kujala scores (97.8 ± 6.4. vs 88.0 ± 6.3, p < 0.005) with low certainty. Four-stranded grafts demonstrated greater Kujala scores than two-stranded grafts (93.5 ± 2.6 vs 91.6 ± 3.5, p = 0.01) with low certainty.

CONCLUSION

The optimal MPFLR surgical technique is likely to utilize a four-stranded graft using either endobutton, double-suture anchor, or transosseous suture patellar fixation with polyester suture augmented interference screw femoral fixation. Orthopedic surgeons can consider employing such a technique to improve patient outcomes by conferring greater graft stability, strength, and function. Level of evidence Level II.

Double-Limb Graft Versus Single-Limb Graft Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation: A Meta-analysis of Randomized Controlled Trials and Cohort Studies

BACKGROUND

The medial patellofemoral ligament (MPFL) is the most important stabilizer of lateral dislocation of the patella. Single-limb (SL) and double-limb (DL) graft MPFL reconstructions have been increasingly used to treat recurrent patellar dislocations, but the clinical efficacy of SL versus DL graft MPFL reconstructions remains controversial owing to the inconsistent conclusions of previous studies.

PURPOSE

This study aimed to compare the clinical outcomes of SL and DL graft MPFL reconstructions for patients with recurrent patellar dislocation by conducting a meta-analysis of randomized controlled trials and cohort studies.

STUDY DESIGN

Meta-analysis; Level of evidence, 3.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched for relevant studies. The retrieval time was up to July 25, 2022. Two evaluators independently screened the literature, extracted data, and assessed the methodological quality of the enrolled studies. Meta-analysis was conducted using RevMan 5.4 software.

RESULTS

A total of 4 randomized controlled trials and 3 cohort studies with 451 patients were included. The joint stability and functional scores in both groups improved significantly from baseline. When compared with SL graft reconstruction, DL graft reconstruction provided reduced recurrent instability (P = .01), anterior patella-related pain (P = .02), and patellar lateral shift rate (P = .02). Regarding functional recovery, patients undergoing DL graft reconstruction presented better scores on the Kujala (P < .001), Tegner (P = .009), and International Knee Documentation Committee (IKDC) (P < .001) but similar Lysholm scores as compared with SL graft reconstruction. No statistically significant difference was found between the techniques in the reduction of the patellar tilt angle, complications other than anterior patella-related pain, or postoperative pain.

CONCLUSION

When compared with SL graft MPFL reconstruction, DL graft MPFL reconstruction yielded better outcomes in terms of postoperative recurrent instability, anterior patella-related pain, patellar lateral shift rate, Kujala score, Tegner score, and IKDC score. The amount of high-quality evidence is insufficient, so this conclusion should be interpreted with caution.

Medium to long-term outcomes of medial patellofemoral ligament reconstruction using the superficial quadriceps versus a hamstring autograft in patellar instability patients

Medial patellofemoral ligament (MPFL) reconstruction is a standard procedure in patellar dislocation patients. Superficial quadriceps autografts (QA) and hamstring autografts (HA) are popular graft choices in MPFL reconstruction with the lack of directly compared clinical studies between both methods. A total of 43 patellar instability patients, who underwent QA and HA for patellar stabilization at a specified center between 2012 and 2021, were retrospectively reviewed. 21 QA and 22 HA patients were 52.4% of males and 47.6% females with a median age of 25 years (range 12-58) in the QA group, while 63.6% were females with a median age of 21 years (range 14-58) in the HA group. The mean follow-up period was 46.9 months (range 24-77) in QA and 61 months (range 24-100) in the HA group. At the final follow-up, no complications were observed with either technique. No patients presented with recurrent dislocations after surgery. There was no statistically significant difference in postoperative mean Kujala scores (QA = 94.9+/- 4.1 and HA = 94.2+/- 8.0, p = 0.73) or the mean Lysholm scores (QA = 94.1+/- 5.0 and HA = 93.2+/- 7.0, p = 0.61).

A Patella-Sided Tensioning Technique for Medial Patellofemoral Ligament Reconstruction

Reconstruction of the medial patellofemoral ligament (MPFL) is a common procedure for treatment of recurrent patellofemoral instability. Over the last two decades, multiple surgical techniques for MPFL reconstruction have been described with no clear consensus on a superior reconstruction technique. Appropriate graft tensioning is one of the most important factors for a successful MPFL reconstruction. Overtensioning of the MPFL graft can lead to patellofemoral joint overload and undertensioning can lead to recurrent instability. Current literature demonstrates descriptions of MPFL reconstruction with final graft tensioning performed off of the femoral side. We describe a technique in this article for performing final graft tensioning from the patellar side, which gives the surgeon an option for intraoperative tension adjustments after evaluating patellar tracking.